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Narendran N, Nilssen PK, Walker CT, Skaggs DL. New technique and case report: Robot-assisted intralaminar screw fixation of spondylolysis in an adolescent. NORTH AMERICAN SPINE SOCIETY JOURNAL 2023; 16:100284. [PMID: 38025938 PMCID: PMC10654584 DOI: 10.1016/j.xnsj.2023.100284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 12/01/2023]
Abstract
Introduction Management of spondylolysis in adolescents is generally successful with conservative management. Uncommonly, surgical fixation is necessary for refractory cases. Direct repair with intralaminar screws is one commonly utilized technique. Recently, less invasive spinal procedures are becoming viable with the enabling of technologies, including robotics. Case description A 14-year-old baseball player and surfer presented with low back pain, diagnosed by MRI as bony edema and stress fractures of the posterior spinal elements. After 18 months, the pain was unresponsive to rest, physical therapy, and bracing. There was no radicular pain or neurologic symptoms. Computed tomography (CT) revealed bilateral, chronic nonhealing pars defects at L5. He underwent outpatient, robot-assisted percutaneous intralaminar fixation with hydroxyapatite-coated screws through a 2 cm skin incision. Outcome On postoperative day 1, the patient reported relief of his preoperative pain and he was ambulating without difficulty. At 2 weeks follow-up, the patient was completely pain free and surfing. At 2 months follow-up, low-dose CT demonstrated partial incorporation of the hydroxyapatite-coated screws, and the patient returned to sports. At 6 months follow-up, the patient had no pain and was swinging his baseball bat with full force. Low-dose CT revealed complete healing of the defects with full incorporation of the hydroxyapatite-coated screws. Conclusions A novel minimally invasive robotic percutaneous approach for direct spondylolysis repair using hydroxyapatite-coated screws is a potential surgical treatment option for non-healing pars defects in adolescent patients.
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Affiliation(s)
- Nakul Narendran
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, 444 South San Vicente Blvd, Los Angeles, CA, United States
| | - Paal K. Nilssen
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, 444 South San Vicente Blvd, Los Angeles, CA, United States
| | - Corey T. Walker
- Department of Neurosurgery, Cedars-Sinai Medical Center, 444 South San Vicente Blvd, Los Angeles, CA, United States
| | - David L. Skaggs
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, 444 South San Vicente Blvd, Los Angeles, CA, United States
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Zhang T, Ma L, Liu H, Yang C, Li S. Comparing the Wiltse approach and classical approach of pedicle screw and hook internal fixation system for direct repair of lumbar spondylolysis in young patients: A case-control study. Medicine (Baltimore) 2023; 102:e34813. [PMID: 37713869 PMCID: PMC10508563 DOI: 10.1097/md.0000000000034813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 07/27/2023] [Indexed: 09/17/2023] Open
Abstract
The aim of this study was to investigate the clinical effect of direct isthmus repair via Wiltse approach and classical approach in the treatment of simple lumbar spondylolysis in young patients. Thirty-three patients with simple lumbar spondylolysis underwent direct isthmic repair via the Wiltse approach (n = 17) or the classical approach (n = 16). The operation time, intraoperative blood loss, postoperative drainage volume, hospital stay, fusion rate, visual analogue scale (VAS), and the Oswestry disability index were evaluated and compared between the 2 groups. The amount of intraoperative blood loss, postoperative drainage volume, and the duration of hospital stay in the Wiltse group were lower than those in the classical group (P < .05). There was no significant difference in Oswestry disability index score between the Wiltse group and the classical group at 3 months, 6 months, and 1 year after operation, but the visual analogue scale score in the Wiltse group was lower than that in the classical group at 6 months after surgery (P < .05). The Wiltse approach was comparable to the classical approach in terms of bone graft fusion time and fusion rate. The Wiltse approach for isthmus repair can achieve the same or even better clinical effect than the classical approach, and the Wiltse approach is more minimally invasive. Pedicle screw-hook internal fixation system combined with autogenous iliac bone graft via Wiltse approach is a feasible, safe, and effective minimally invasive surgical method for the repair of isthmic spondylolysis in young patients.
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Affiliation(s)
- Tao Zhang
- Department of Spine Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese PLA, Lanzhou, China
| | - Lihua Ma
- The First Hospital of Lanzhou University, Lanzhou, China
| | - Hua Liu
- Department of Spine Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese PLA, Lanzhou, China
| | - Chengwei Yang
- Department of Spine Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese PLA, Lanzhou, China
| | - Songkai Li
- Department of Spine Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese PLA, Lanzhou, China
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Surgical Reduction and Direct Repair Using Pedicle Screw-Rod-Hook Fixation in Adult Patients with Low-Grade Isthmic Spondylolisthesis. Pain Res Manag 2022; 2022:8410519. [PMID: 35991588 PMCID: PMC9385336 DOI: 10.1155/2022/8410519] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/28/2022] [Indexed: 11/17/2022]
Abstract
Background Although direct pars repair using a pedicle screw-rod-hook system has achieved satisfactory results in patients with spondylolysis, its application in adults with low-grade isthmic spondylolisthesis is rarely reported. Objective To assess the surgical effect of reduction and direct repair surgery with a pedicle screw-rod-hook system combined with autogenous bone grafts in adult patients with low-grade isthmic spondylolisthesis. Methods Sixty-four adult patients with low-grade isthmic spondylolisthesis underwent reduction and direct repair using a pedicle screw-rod-hook system in our department from September 2009 to April 2018. The clinical efficacy was evaluated by clinical and radiological assessments. Results The average follow-up was 52.15 ± 9.96 months. The visual analog scale (VAS) scores (VAS-lumbar and VAS-leg) and Oswestry Disability Index (ODI) at the final follow-up (FFU) were significantly lower than the preoperative levels (P < 0.05). The modified Prolo score was “excellent” for 60 patients (93.75%) and “good” for 4 patients (6.25%). The slip distance and slipping percentage showed significant decreases postoperatively and FFU compared to preoperatively (P < 0.05). There were no significant differences in the disc height, slip angle, and range of motion of the surgical intervertebral space or upper intervertebral space between preoperation and FFU (P < 0.05). Successful bony fusion had a 96.86% success rate. Conclusion Reduction of slip and direct repair using pedicle screw-rod-hook fixation combined with autogenous iliac bone grafting in adult patients with low-grade isthmic spondylolisthesis is a safe and effective technique.
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Clinical results of restoration of pars interarticularis defect in adults with percutaneous intralaminar screw fixation. World Neurosurg 2022; 164:e290-e299. [PMID: 35552035 DOI: 10.1016/j.wneu.2022.04.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 04/22/2022] [Accepted: 04/23/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE This study aims to report the clinical outcomes associated with the percutaneous intralaminar screw repair performed for pars defects in adults. METHODS Adult patients who got their lumbar L5 spondylolysis repaired via the modified Buck's procedure between 2017 and 2020 were retrospectively evaluated. The preoperative and postoperative clinical outcomes at 1, 3, 6, and 12 months were evaluated for patients with and without fusion using the visual analog scale (VAS), Oswetry Disability Index (ODI), and the Short Form Health Survey 36 (SF-36). At 12 months, the fusion status of all the patients was assessed using bilateral direct X-rays. RESULTS Thirty patients with spondylolysis were identified (11 men and 19 women). All patients had bilateral L5 pars defects, and at 12 months, the fusion rate was 60% (18/30). There was no difference between the fusion and nonfusion groups in terms of their VAS, ODI, SF-36-physical component summary (PCS), and SF-36-mental component summary (MCS) scores (p > 0.05). Within-group comparisons of the two groups revealed significant changes at follow-up (p < 0.05). CONCLUSIONS Minimally invasive repair of lumbar spondylolysis with percutaneous intralaminar screw fixation restores the motion segment and can provide early resumption of physical activity with minimal muscle damage, smaller skin incision, and less soft tissue dissection.
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Linton AA, Hsu WK. A Review of Treatment for Acute and Chronic Pars Fractures in the Lumbar Spine. Curr Rev Musculoskelet Med 2022; 15:259-271. [DOI: 10.1007/s12178-022-09760-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2022] [Indexed: 11/24/2022]
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Kumar N, Madhu S, Pandita N, Ramos MRD, Tan BWL, Lopez KG, Alathur Ramakrishnan S, Jonathan P, Nolan CP, Shree Kumar D. Is there a place for surgical repair in adults with spondylolysis or grade-I spondylolisthesis-a systematic review and treatment algorithm. Spine J 2021; 21:1268-1285. [PMID: 33757872 DOI: 10.1016/j.spinee.2021.03.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/13/2021] [Accepted: 03/16/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Pars repair is less explored in adults due to associated disc degeneration with advancing age. The aim of our systematic review was to define optimal characteristics of adults with spondylolysis/grade-I spondylolisthesis suitable for pars repair and evaluate the feasibility, effectiveness, and safety of standard repair techniques in these adults. METHODS This systematic review is reported in line with PRISMA-P and protocol is registered with PROSPERO (CRD42020189208). Electronic searches were conducted in PubMed, Embase, Scopus, and Web of Science in June 2020 using systematic search strategy. Studies involving adults aged ≥18-years with spondylolysis/grade-1 isthmic spondylolisthesis treated with standard pars repair techniques were considered eligible. A two-staged (titles/abstracts and full-text) screening was conducted independently by three authors followed by quality assessment using the Joanna Briggs Institute critical appraisal checklist for selection of final articles for narrative synthesis. RESULTS A total of 5,813-articles were retrieved using systematic search strategy. First screening followed by removal of duplicates resulted in 111-articles. Second (full-text) screening resulted in exclusion of 64-articles. A final 47-articles were considered for data extraction after quality assessment. A total of 590-adults were enrolled across 47-studies; 93% were 'young adults' (18-35 years); 82% were males. Persistent low back pain was the common presenting complaint. Lysis defect was primarily bilateral (96.4%) and L5 was the most involved level (68.5%). Majority had no disc degeneration (83.5%) and had spondylolysis as the primary diagnosis (86%); only 14% had grade-I spondylolisthesis. Pars infiltration test was conducted in 22-studies and discography in 8-studies. Duration of prior conservative therapy was 3 to 72-months. Buck's repair was the commonest technique (27-studies, 372-adults). Successful repair was reported in 86% of patients treated with Buck's and ≥90% treated with Scott's, Morscher's and pedicle-screw-based techniques. Improvement in pain/functional outcomes, union rate and rate-of-return to sports/activity was high and comparable across all techniques. Intraoperative blood loss was low with minimally invasive versus traditional repair. The overall complication rate was 11.9%, with implant failure being the major complication. CONCLUSIONS Our systematic review establishes a definite place for lysis repair in carefully selected adults with spondylolysis/grade-I spondylolisthesis. We propose a treatment algorithm for optimizing patient selection and outcomes. We conclude that adults with age 18 to 45 years, no/mild disc or facet degenerative changes, positive diagnostic infiltration test, and normal preoperative discography will have successful outcomes with pars repair, regardless of the technique.
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Affiliation(s)
- Naresh Kumar
- Department of Orthopaedic Surgery, National University Health System, Singapore.
| | - Sirisha Madhu
- Department of Orthopaedic Surgery, National University Health System, Singapore
| | - Naveen Pandita
- Department of Orthopaedic Surgery, National University Health System, Singapore
| | - Miguel R D Ramos
- Department of Orthopaedic Surgery, National University Health System, Singapore
| | - Barry W L Tan
- Department of Orthopaedic Surgery, National University Health System, Singapore
| | - Keith G Lopez
- Department of Orthopaedic Surgery, National University Health System, Singapore
| | | | - Paul Jonathan
- Department of Orthopaedic Surgery, National University Health System, Singapore
| | - Colum P Nolan
- Department of Neurosurgery, National Neuroscience Institute, Singapore
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CONSIDERATION OF SPORT DEMANDS FOR AN 18-YEAR-OLD LACROSSE PLAYER WITH RECALCITRANT SYMPTOMATIC SPONDYLOLYSIS: A CASE REPORT. Int J Sports Phys Ther 2020; 15:1196-1210. [PMID: 33344035 DOI: 10.26603/ijspt20201196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background and Purpose Spondylolysis is an anatomical defect or fracture of the pars interarticularis and encompasses almost half of all cases of low back pain in adolescent athletes. Most athletes return to sport with conservative treatment, but it is possible that consideration of sport demands may further improve rate of successful return. When surgery is performed, complication rate is high, so all conservative measures should be explored before considering surgical intervention. The purpose of this case report is to present a program where demands of sport were considered and allowed successful return to sport for a subject with recalcitrant symptomatic spondylolysis that had failed to respond to prior treatment. Case Description An 18-year-old lacrosse player with a history of recalcitrant symptomatic spondylolysis that failed three courses of conservative treatment and had been unsuccessful in returning to sport. A multi-phase program with a focus on multi-planar and full kinetic chain activities that addressed the nature of the sport demands is described, along with improvements in pain level, strength, range of motion, and subjective outcome scores. Outcomes The subject was able to successfully return to sport after 10 weeks of physical therapy and complete the remaining few months of his lacrosse season without reinjury. Range of motion and strength testing was markedly improved upon discharge. The subject's Modified Oswestry Disability Index improved from 16% to 0% and his pain level did not rise above 2/10 with any sport activity upon return. Discussion/Conclusions Although return to sport rates following spondylolysis in young athletes is high, this case report demonstrates that a consideration of sport demands may increase return to sport rates in athletes that do not respond to standard care and prevent surgical intervention. Level of Evidence Level 4, single case report.
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Oshima Y, Inanami H, Iwai H, Koga H, Takano Y, Oshina M, Oka H, Tanaka S. Is Microendoscopic Discectomy Effective for Patients With Concomitant Lumbar Disc Herniation and Spondylolysis? Global Spine J 2020; 10:700-705. [PMID: 32707024 PMCID: PMC7383789 DOI: 10.1177/2192568219868970] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
STUDY DESIGN A retrospective cohort study. OBJECTIVE Although it is controversial whether to choose only discectomy or fusion surgery in patients with disc herniation and spondylolysis, we expected that aggravation of the spondylolysis may be prevented if posterior supporting muscles can be well-preserved without extensive exploration. The purpose of this study was to investigate the influence of L5 spondylolysis on surgical outcomes following microendoscopic discectomy (MED) in patients with concomitant lumbar disc herniation and spondylolysis. METHODS We reviewed 811 patients who underwent MED for L4/5 or L5/S1 disc herniation. Patients with spondylolisthesis were excluded. We compared surgical outcomes of patients with and without L5 spondylolysis, whose age, sex, and surgical level were matched. RESULTS A total of 655 patients (80.7%) with complete data were considered eligible for the study. MED was performed at L4/5 and L5/S1 in 338 and 317 patients, respectively. A total of 20 patients (3.1%) had concomitant L5 spondylolysis and disc herniation at L4/5 (9 patients) or L5S1 (11 patients). As we compared each outcome of the 20 patients having L5 spondylolysis with 40 matched patients without L5 spondylosis, there were no significant differences in preoperative or postoperative outcomes between the 2 groups, and no patient with spondylolysis had undergone additional surgery during the mean follow-up period of 24 months. CONCLUSIONS MED demonstrated good surgical results regardless of the presence or absence of spondylolysis. In patients with sciatica with concomitant disc herniation and spondylolysis, but without spondylolisthesis, fusion surgery may not be always necessary.
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Affiliation(s)
- Yasushi Oshima
- The University of Tokyo, Tokyo, Japan
- Yasushi Oshima, Department of Orthopaedic Surgery, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
| | | | - Hiroki Iwai
- Iwai Orthopaedic Medical Hospital, Tokyo, Japan
| | | | | | | | - Hiroyuki Oka
- 22nd Century Medical & Research Center, The University of Tokyo, Tokyo, Japan
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Jin M, Zhang J, Shao H, Liu J, Zhao T, Huang Y. Percutaneous endoscopic-assisted direct repair of pars defect without general anesthesia could be a satisfying treatment alternative for young patient with symptomatic lumbar spondylolysis: a technique note with case series. BMC Musculoskelet Disord 2020; 21:340. [PMID: 32487055 PMCID: PMC7268338 DOI: 10.1186/s12891-020-03365-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 05/25/2020] [Indexed: 02/08/2023] Open
Abstract
Background Multiple surgical procedures are applied in young patients with symptomatic lumbar spondylolysis when conservative treatments fail. Although the optimal surgical procedure option is controversial, the treatment paradigm has shifted from open surgery to minimally invasive spine surgery. To date, a limited number of studies on the feasibility of percutaneous endoscopic-assisted direct repair of pars defect have been carried out. Herein, for the first time, we retrospectively explore the outcomes of pars defect via percutaneous endoscopy. Methods We retrospectively examined young patients with spondylolysis treated using the percutaneous endoscopic-assisted direct repair of pars defect supplemented with autograft as well as percutaneous pedicle screw fixation between September 2014 and December 2018. Six patients with a mean age of 18.8 years were enrolled in the study. We used preoperatively computed tomographic (CT) scans to evaluate the size of pars defect, and graded disc degeneration using Pfirrmann’s classification through magnetic resonance images (MRI). We assessed the clinical outcomes using the Oswestry Disability Index (ODI), 36-Item Short-Form Health Survey (SF-36) as well as Visual Analogue Scale for back pain (VAS-B). Results Our findings revealed that pain intensity and function outcomes, including VAS-B, ODI, and SF-36 (PCS and MCS) scores, were markedly improved after surgery and at the final follow-up visit. The change in the gap distance of the pars defect was remarkably significant after surgery and during the follow-up period. Only one of the 12 pars repaired was reported as a non-union at the final follow-up visit. Moreover, no surgery-related complications were reported in any of the cases. Conclusion Percutaneous endoscopic-assisted direct repair of pars defect without general anesthesia, a minimally invasive treatment option, supplemented with autograft and percutaneous pedicle screw fixation, could be a satisfying treatment alternative for young patients with symptomatic lumbar spondylolysis.
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Affiliation(s)
- Mengran Jin
- Department of Orthopaedics, Zhejiang Provincial People's Hospital, Shangtang Road No. 158, Hangzhou, 310014, Zhejiang Province, China.,People's Hospital of Hangzhou Medical College, Zhejiang Provincial People's Hospital, Hangzhou, 310014, Zhejiang Province, China
| | - Jun Zhang
- Department of Orthopaedics, Zhejiang Provincial People's Hospital, Shangtang Road No. 158, Hangzhou, 310014, Zhejiang Province, China.,People's Hospital of Hangzhou Medical College, Zhejiang Provincial People's Hospital, Hangzhou, 310014, Zhejiang Province, China
| | - Haiyu Shao
- Department of Orthopaedics, Zhejiang Provincial People's Hospital, Shangtang Road No. 158, Hangzhou, 310014, Zhejiang Province, China.,People's Hospital of Hangzhou Medical College, Zhejiang Provincial People's Hospital, Hangzhou, 310014, Zhejiang Province, China
| | - Jianwen Liu
- Department of Orthopaedics, Zhejiang Provincial People's Hospital, Shangtang Road No. 158, Hangzhou, 310014, Zhejiang Province, China.,People's Hospital of Hangzhou Medical College, Zhejiang Provincial People's Hospital, Hangzhou, 310014, Zhejiang Province, China
| | - Tingxiao Zhao
- Department of Orthopaedics, Zhejiang Provincial People's Hospital, Shangtang Road No. 158, Hangzhou, 310014, Zhejiang Province, China.,People's Hospital of Hangzhou Medical College, Zhejiang Provincial People's Hospital, Hangzhou, 310014, Zhejiang Province, China
| | - Yazeng Huang
- Department of Orthopaedics, Zhejiang Provincial People's Hospital, Shangtang Road No. 158, Hangzhou, 310014, Zhejiang Province, China. .,People's Hospital of Hangzhou Medical College, Zhejiang Provincial People's Hospital, Hangzhou, 310014, Zhejiang Province, China.
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Bony stress in the lumbar spine is associated with intervertebral disc degeneration and low back pain: a retrospective case-control MRI study of patients under 25 years of age. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:2470-2477. [PMID: 31529214 DOI: 10.1007/s00586-019-06148-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 08/04/2019] [Accepted: 09/10/2019] [Indexed: 12/15/2022]
Abstract
PURPOSE Abnormal stress in the lumbar vertebra, also known as bony stress, can be a precursor to degenerative changes which may manifest as low back pain (LBP). However, the prevalence of bony stress in the lumbar spine and its relationship with degenerative changes and LBP is unclear. The purpose of this study was to evaluate the prevalence of bony stress in the lumbar spine and its relationship with intervertebral disc (IVD) degeneration, facet osteoarthritis and LBP in patients under 25 years of age. METHODS A retrospective case-control study of 130 patients under 25 years of age was conducted from a population of 493 patients who had lumbar MRI across three imaging centres over three years. A cohort of 55 consecutive patients with bony stress was identified. A control group of consecutive patients (n = 75) without bony stress was also selected from the population. RESULTS Bony stress was prevalent in 11% (95% CI [8.4-14.5%]) of patients and was not diagnosed in 36% (95% CI [22-55%]) of these cases. Patients with bony stress had over twofold (OR 2.3, 95% CI [1.1-4.8]) and fivefold (OR 5.3, 95% CI [2.11-13.3]) higher likelihood of having IVD degeneration and LBP, respectively, when compared with the control group. Bony stress was not found to be associated with facet osteoarthritis. CONCLUSION Bony stress in the lumbar spine was prevalent in 11% of patients under 25 years of age. It was commonly undiagnosed in radiology reports (not reported in 36% of the cases). Being significantly associated and with an increased likelihood of IVD degeneration and LBP, we posit that bony stress is likely a symptomatic and clinically meaningful diagnostic entity in the assessment of LBP. These slides can be retrieved under Electronic Supplementary Material.
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Abstract
PURPOSE OF REVIEW Provide a comprehensive overview of lumbar spondylolysis, a frequent cause of lower back pain in children and adolescents, from evaluation to management. RECENT FINDINGS With the surge of structured sports participation in the pediatric population, spondylolysis is a common ailment that afflicts many young athletes due to rigorous competition that taxes the growing spine with repetitive extension and rotation. SUMMARY Spondylolysis is a fracture through the pars interarticularis. When a child presents with lower back pain, spondylolysis should be at the top of the differential. A thorough history and physical examination are essential. In addition, radiographs of the lumbar spine, anterior posterior and lateral views, MRI and, selectively, computed tomography are useful adjuncts to uncover a pars injury. Timely diagnosis facilitates early treatment which includes rest, optimizing bone health, brace treatment, and physical therapy. If delayed or untreated, spondylolysis may result in nonunion or pars defect. If symptomatic, patients may need surgery to fuse the lumbar facet joints or repair the par interarticularis.
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Gagnet P, Kern K, Andrews K, Elgafy H, Ebraheim N. Spondylolysis and spondylolisthesis: A review of the literature. J Orthop 2018; 15:404-407. [PMID: 29881164 PMCID: PMC5990218 DOI: 10.1016/j.jor.2018.03.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 03/16/2018] [Indexed: 02/07/2023] Open
Abstract
Spondylolysis is a common diagnosis with a high prevalence in children and adolescents complaining of low back pain. It may be caused by either a defect or fracture of the pars interarticularis due to mechanical stress. Depending on the severity of the spondylolysis and symptoms associated it may be treated either conservatively or surgically, both of which have shown significant success. Conservative treatments such as bracing and decreased activity have been shown to be most effective with patients who have early diagnosis and treatment. Low-intensity pulsed ultrasound (LIPUS) in addition to conservative treatment appears to be very promising for achieving a higher rate of bony union. LIPUS requires more supporting studies, but may prove to become a standard of care in the future. Surgery may be required if conservative treatment, for at least six months, failed to give sustained pain relief for the activities of daily living. Based on studies performed on each of the major surgical treatments we suggest the use of the pedicle screw hook technique and the pedicle screw rod technique due to low rates of hardware failure, increased maintenance of mobility, and lack of a postoperative bracing requirement.
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Affiliation(s)
- Paul Gagnet
- Department of Orthopaedic Surgery, University of Toledo Medical Center, 3000 Arlington Avenue, Toledo, OH, USA
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Sharma A, Sargar K, Salter A. Temporal Evolution of Disc in Young Patients with Low Back Pain and Stress Reaction in Lumbar Vertebrae. AJNR Am J Neuroradiol 2017; 38:1647-1652. [PMID: 28572152 DOI: 10.3174/ajnr.a5237] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 03/17/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND PURPOSE Although stress-induced bony changes often resolve with conservative treatment, the long-term effects of such mechanical stresses on intervertebral discs have not been studied. We aimed to assess the differences in the temporal evolution of disc in segments of the lumbar spine with and without signs of increased mechanical stresses. MATERIALS AND METHODS Using MR imaging performed >6 months apart, 2 radiologists evaluated lumbar intervertebral discs for degenerative changes affecting the annulus fibrosus, the nucleus pulposus, and the endplates in 42 patients (22 male, 20 female; mean age, 16.0 ± 3.7 years [range, 7-25 years]) with low back pain and imaging evidence of stress reaction/fracture in the lumbar spine. Data were analyzed for differences in the presence and progression of disc degeneration in stressed versus nonstressed segments. RESULTS At baseline, stressed discs had a higher burden of annular fissures, radial fissures, herniation, and nuclear degeneration. Endplate defect burden was comparable in stressed and control discs. At follow-up, the burden of new annular fissures and endplate defects was comparable for stressed and control discs. However, a higher proportion of stressed discs showed worsening nuclear signal intensity grade (14.3% versus 0% control discs; P = .008) and worsening nuclear degeneration grade (11.9% versus 0% control discs; P = .02). An increased risk of progressive nuclear degeneration of stressed discs was observed irrespective of the outcome of bony changes. CONCLUSIONS Stressed discs exhibit a higher burden of nuclear and annular degeneration at baseline. These discs have a higher risk of progressive nuclear degeneration irrespective of improvement or worsening of stress-related bony changes.
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Affiliation(s)
- A Sharma
- From the Mallinckrodt Institute of Radiology (A. Sharma, K.S.) .,Department of Radiology (A. Sharma), Barnes-Jewish Hospital South, St. Louis, Missouri.,Department of Radiology (A. Sharma), St. Louis Children's Hospital, St. Louis, Missouri
| | - K Sargar
- From the Mallinckrodt Institute of Radiology (A. Sharma, K.S.)
| | - A Salter
- Department of Biostatistics (A. Salter), Washington University School of Medicine, St. Louis, Missouri
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